Associations of modern initial antiretroviral drug regimens with all-cause mortality in adults with HIV in Europe and North America: a cohort study

Epidemiology, treatment and prognosis of HIV infection in 2024: A practical review

In recent years, the epidemiology and prognosis of HIV infection have undergone significant changes thanks to the recommendation of antiretroviral therapy (ART) for all infected persons, the development of more effective and better tolerated drugs, and preventive measures such as pre-exposure prophylaxis (PrEP). The evolution of ART, now with simple oral and injectable options, has also contributed to improvements in comprehensive HIV treatment and care. With early diagnosis and early initiation of ART, the life expectancy of people with HIV has reached the same as the general population. However, many people with HIV remain undiagnosed or are diagnosed late, and some population groups experience greater vulnerability, affecting individual and collective health. In this review we review the current epidemiology, treatment and prognosis of HIV infection.

Integrase inhibitors: current protagonists in antiretroviral therapy

Since HIV was identified as the etiological agent of AIDS, there have been significant advances in antiretroviral therapy (ART) that has reduced morbidity/mortality. Still, the viral genome's high mutation rate, suboptimal ART regimens, incomplete adherence to therapy and poor control of the viral load generate variants resistant to multiple drugs. Licensing over 30 anti-HIV drugs worldwide, including integrase inhibitors, has marked a milestone since they are potent and well-tolerated drugs. In addition, they favor a faster recovery of CD4+ T cells. They also increase the diversity profile of the gut microbiota and reduce inflammatory markers. All of these highlight the importance of including them in different ART regimens.

Bifurcation analysis of multistability and hysteresis in a model of HIV infection

The infectious disease caused by human immunodeficiency virus type 1 (HIV-1) remains a serious threat to hu- man health. The current approach to HIV-1 treatment is based on the use of highly active antiretroviral therapy, which has side effects and is costly. For clinical practice, it is highly important to create functional cures that can enhance immune control of viral growth and infection of target cells with a subsequent reduction in viral load and restoration of the immune status. HIV-1 control efforts with reliance on immunotherapy remain at a conceptual stage due to the complexity of a set of processes that regulate the dynamics of infection and immune response. For this reason, it is extremely important to use methods of mathematical modeling of HIV-1 infection dynamics for theoretical analysis of possibilities of reducing the viral load by affecting the immune system without the usage of antiviral therapy. The aim of our study is to examine the existence of bi-, multistability and hysteresis properties with a meaningful mathematical model of HIV-1 infection. The model describes the most important blocks of the processes of interaction between viruses and the human body, namely, the spread of infection in productively and latently infected cells, the appearance of viral mutants and the develop- ment of the T cell immune response. Furthermore, our analysis aims to study the possibilities of transferring the clinical pattern of the disease from a more severe state to a milder one. We analyze numerically the conditions for the existence of steady states of the mathematical model of HIV-1 infection for the numerical values of model parameters correspond- ing to phenotypically different variants of the infectious disease course. To this end, original computational methods of bifurcation analysis of mathematical models formulated with systems of ordinary differential equations and delay differ- ential equations are used. The macrophage activation rate constant is considered as a bifurcation parameter. The regions in the model parameter space, in particular, for the rate of activation of innate immune cells (macrophages), in which the properties of bi-, multistability and hysteresis are expressed, have been identified, and the features characterizing transi- tion kinetics between stable equilibrium states have been explored. Overall, the results of bifurcation analysis of the HIV-1 infection model form a theoretical basis for the development of combination immune-based therapeutic approaches to HIV-1 treatment. In particular, the results of the study of the HIV-1 infection model for parameter sets corresponding to different phenotypes of disease dynamics (typical, long-term non-progressing and rapidly progressing courses) indicate that an effective functional treatment (cure) of HIV-1-infected patients requires the development of a personalized ap- proach that takes into account both the properties of the HIV-1 quasispecies population and the patient's immune status.

Longitudinal trajectories of weight changes among people living with HIV on antiretroviral therapy: A group-based study

Weight changes vary among people living with HIV (PLHIV) on different antiretroviral therapy (ART) regimens. Here, we performed multi-trajectory modeling fitting growth mixture models (GMM) to identify longitudinal weight change trajectories of PLHIV. Multiple logistic regression was used to assess correlates of rapid weight gains; 12,683 PLHIV (median age: 34 years [interquartile range 29-42], 91.1% male) who initiated ART at the Third People's Hospital of Shenzhen, China, between January 2003 and September 2022 were included. We identified two trajectories: slow (70.5%) and rapid weight gains (29.5%). PLHIV who initiated ART with dolutegravir- (adjusted odds ratio [aOR] 2.46, 1.92-3.15), raltegravir- (2.74, 1.96-3.82), and lopinavir (1.62, 1.36-1.94)-based regimens were more likely to have rapid weight gains compared with efavirenz-based regimen. The monitoring of nutritional status should be strengthened for PLHIV who initiated these regimens during regular ART follow-ups.

Pillars of long-term antiretroviral therapy success

BACKGROUND

Meeting the challenge of antiretroviral therapy (ART) whose efficacy can last a lifetime requires continuous updating of the virological, pharmacological, and quality of life outcomes to be pursued and a continuous review of literature data on the efficacy and tolerability of new drugs and therapeutic strategies.

METHODS

With the aim of identifying open questions and answers about the current controversies in modern ART, we adapted the Design Thinking methodology to the needs of the design phase of a scientific article, involving a team of experts in HIV care.

RESULTS

Five main pillars of treatment success were discussed: sustained virologic suppression over time; immunological recovery; pharmacological attributes; long-term tolerability and safety of ART; and people's satisfaction and quality of life. The definition of the outcomes to be achieved in each thematic area and the tools to achieve them were reviewed and discussed.

CONCLUSIONS

Long-term treatment success should be intended as a combination of HIV-RNA suppression, immune recovery, and high quality of life. To achieve this, the regimen should be well-tolerated, with high potency, genetic barrier, and forgiveness, and should be tailored by a person-centered perspective, based on individual needs, preferences, and therapeutic history.

Prevention, treatment and cure of HIV infection

The development of antiretroviral therapy for the prevention and treatment of HIV infection has been marked by a series of remarkable successes. However, the efforts to develop a vaccine have largely failed, and efforts to discover a cure are only now beginning to gain traction. In this Review, we describe recent progress on all fronts - pre-exposure prophylaxis, vaccines, treatment and cure - and we discuss the unmet needs, both current and in the coming years. We describe the emerging arsenal of drugs, biologics and strategies that will hopefully address these needs. Although HIV research has largely been siloed in the past, this is changing, as the emerging research agenda is marked by multiple cross-discipline synergies and collaborations. As the limitations of antiretroviral drugs as a means to truly end the epidemic are becoming more apparent, there is a great need for continued efforts to develop an effective preventative vaccine and a scalable cure, both of which remain formidable challenges.

Associations of modern initial antiretroviral therapy regimens with all-cause mortality in people living with HIV in resource-limited settings: a retrospective multicenter cohort study in China

Despite the proven virological advantages, there remains some controversy regarding whether first-line integrase strand transfer inhibitors (INSTIs)-based antiretroviral therapy (ART) contributes to reducing mortality of people living with HIV (PLHIV) in clinical practice. Here we report a retrospective study comparing all-cause mortality among PLHIV in China who were on different initial ART regimens (nevirapine, efavirenz, dolutegravir, lopinavir, and others [including darunavir, raltegravie, elvitegravir and rilpivirine]) between 2017 and 2019. A total of 41,018 individuals were included across China, representing 21.3% of newly reported HIV/AIDS cases collectively in the country during this period. Only the differences in all-cause mortality of PLHIV between the efavirenz group and the nevirapine group, the dolutegravir group and the nevirapine group, and the lopinavir group and the nevirapine group, were observed in China. After stratifying the cause of mortality, we found that the differences in mortality between initial ART regimens were mainly observed in AIDS-related mortality.

Long-Term Benefits from Early Antiretroviral Therapy Initiation in HIV Infection

BACKGROUND

For people with HIV and CD4+ counts >500 cells/mm3, early initiation of antiretroviral therapy (ART) reduces serious AIDS and serious non-AIDS (SNA) risk compared with deferral of treatment until CD4+ counts are <350 cells/mm3. Whether excess risk of AIDS and SNA persists once ART is initiated for those who defer treatment is uncertain.

METHODS

The Strategic Timing of AntiRetroviral Treatment (START) trial, as previously reported, randomly assigned 4684 ART-naive HIV-positive adults with CD4+ counts .500 cells/mm3 to immediate treatment initiation after random assignment (n = 2325) or deferred treatment (n= 2359). In 2015, a 57% lower risk of the primary end point (AIDS, SNA, or death) for the immediate group was reported, and the deferred group was offered ART. This article reports the follow-up that continued to December 31, 2021. Cox proportional-hazards models were used to compare hazard ratios for the primary end point from randomization through December 31, 2015, versus January 1, 2016, through December 31, 2021.

RESULTS

Through December 31, 2015, approximately 7 months after the cutoff date from the previous report, the median CD4+ count was 648 and 460 cells/mm3 in the immediate and deferred groups, respectively, at treatment initiation. The percentage of follow-up time spent taking ART was 95% and 36% for the immediate and deferred groups, respectively, and the time-averaged CD4+ difference was 199 cells/mm3. After January 1, 2016, the percentage of follow-up time on treatment was 97.2% and 94.1% for the immediate and deferred groups, respectively, and the CD4+ count difference was 155 cells/mm3. After January 1, 2016, a total of 89 immediate and 113 deferred group participants experienced a primary end point (hazard ratio of 0.79 [95% confidence interval, 0.60 to 1.04] versus hazard ratio of 0.47 [95% confidence interval, 0.34 to 0.65; P<0.001]) before 2016 (P=0.02 for hazard ratio difference).

CONCLUSIONS

Among adults with CD4+ counts >500 cells/mm3, excess risk of AIDS and SNA associated with delaying treatment initiation was diminished after ART initiation, but persistent excess risk remained. (Funded by the National Institute of Allergy and Infectious Diseases and others.).